Insurance for the business needing workers comp in Georgia

Application

Start the application process with the form below… We provide workers comp quotes once the online application is submitted.

Application-General Data

Business Name
Type of Business
Your Name(required)
Email(valid email required)
Website
Phone Number(required)
Years in Business
Street Address
City
State
Zip(required)
States You Do Business In
Federal Tax ID number or Social

Mulitiple Locations

List Addressses of all company locations:

Policy Info

Proposed Effective Date
States to be included in coverage
Preferred Coverage Amount

Rating Information

Workers Comp rates the policy based on the what the worker does. Breaking out each classs of worker ensures the proper rating on a per class basis. Example: Clarical Office Staff - 4 full time 2 part time payroll totaling x.xx.
Class of Worker
How Many Full and Part time
Estimated Yearly Payroll for this Class of worker
Class or Worker
How Many Full and Part time
Estimated Yearly Payroll for this Class of worker
Class of Worker
How Many Full and Part time
Estimated Yearly Payroll for this Class of worker
Class of Worker
How Many Full and Part time
Estimated Yearly Payroll for this Class of worker

Prior Carrier Loss History

Please list loss history from prior carrier.

Individuals to be included/excluded from coverage

Owner's Name (required)
Owner's Birthdate(required)
Owner's title(required)
% of Ownership(required)
Include or Exclude(required)
Estimated Payroll
Owner's Name
Owner's Birthdate
Owner's title
% of Ownership
Include or Exclude
Estimated Payroll
Owner's Name
Owner's Birthdate
Owner's title
% of Ownership
Include or Exclude
Estimated Payroll

Nature of Businsess

Describe Business
Enter Loss History:no loss history

Validation

Ten minus five equals

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